Kids Care Assurance Sign-Up Form

Get affordable, reliable pediatric care for your family. Complete the form below to join.

Child's Full Name

Date of Birth *

Gender

Parent/Guardian's Name

Number of Children

For every additional child, the fee increases by $50.

Phone Number *

Additional Notes

The plan is activated in-house once payment is received.

I understand that this is a membership-based plan and activation requires in-house payment.